Former Phoenix Mayor Greg Stanton, Now Rep.-Elect Santon, said he was eager to get to work as he joined more than 80 newly elected members of Congress during a freshman orientation session in Washington. (Photo by Renata Cló/ Cronkite News)

WASHINGTON – Arizona’s two newest members of Congress joined more than 80 other newly elected House members for freshmen orientation Tuesday, as Democrats prepare to seize control of the lower chamber for the first time in eight years.

Former Phoenix Mayor Greg Stanton and two-time former Rep. Ann Kirkpatrick, both Democrats, are also part of a shift in control of the state’s congressional delegation.

With the election of Democrat Kyrsten Sinema to the Senate, Arizona will be represented by six Democrats and five Republicans in Washington – a gain of one Democratic seat in the House and Senate over the current Congress.

One expert called it evidence that Arizona is transitioning from a “straight Republican” state to a “solid purple state.”

But Stanton on Tuesday said he plans to focus on bipartisanship in his new role in Washington, and is eager to get to work.

“I’m the big-city mayor, so of course I’m interested in infrastructure investment and really feel like Washington has gotten away from partnering with the cities on infrastructure investment,” Stanton said.

He said he recognizes he won in a “competitive district” and a lot of Republicans and independents voted for him. “I’m going to be a bipartisan leader focusing on getting things done,” he said.

But Democrats will have the upper hand in the House for the first time since 2010, with Democrats accounting for 56 of the 87 freshmen scheduled to be on hand for orientation this week and next.

Kirkpatrick, who could not be contacted for comment Tuesday, is a freshman in name only. She was elected in 2008 and defeated after one term, then elected again in 2012, serving for two terms before losing a Senate bid to Sen. John McCain, R-Arizona, in 2016. After being elected from northern Arizona districts before, she was elected this year from the 2nd District in Tucson.

​Besides the change in location, however, Arizona pollster Mike Noble said he expects to see little change on issues from Kirkpatrick from her earlier terms in Congress.

Noble also said he expects Stanton to “keep fighting for Arizona,” and focus on education issues, as well continuing to work to attract businesses to the state.Noble said Arizonans will likely see more candidates positioning themselves toward the center in future elections, in response to a shifting political climate in the state.

Joseph Garcia, at Arizona State University’s Morrison Institute for Public Policy, agreed.

“There’s a lot of people in the middle and candidates that can play into the middle and still collect a good amount of people either on the right or on the left have a very good chance of being elected,” said Garcia, director of the Morrison Institute’s Latino Public Policy Center.

And he said it’s already happening, noting that running as an independent and “not bragging of being a Democrat” worked for Sinema.

“I don’t think anybody was thinking early on that the Senate position was going to go to a Democrat in Arizona anytime soon, but I think it’s somewhat of a snapshot or look into the future,” he said.

He said that in that future, as “more and more Latinos become 18 years old, and eligible to vote, Arizona is moving from a red conservative state to become a blue progressive state.”

“We’re talking maybe 10, 12 years down the road,” Garcia said. “But in that time period, Arizona will be very solidly purple.”

Enrollment for Affordable Care Act - Obamacare - for 2019 runs from Nov. 1 to Dec. 15, with potential customers in Arizona seeing more choices and lower prices, on average, than they did during open enrollment period last year. (Photo by Alex Poimos/ Creative Commons)

WASHINGTON – Open enrollment began Thursday for health insurance under the Affordable Care Act, with most Arizonans seeing more choices and better prices, a sharp change from recent years when the state was the poster child for Obamacare problems.

The Department of Health and Human Services said five companies will offer 18 qualified health insurance plans in Arizona for next year, with premiums on average expected to be 10 percent lower than this year. Open enrollment runs through Dec. 15.

Those improvements will mostly be concentrated in urban areas of the state. Residents of rural counties will have fewer companies to choose from and prices may actually go up in some places.

But experts say the market appears to be finally settling down and consumers in the state should not see the swings that led President Donald Trump to hold up Arizona as “ground zero for everything that was wrong with the Affordable Care Act,” in the words of Swapna Reddy, clinical assistant professor at Arizona State University’s College of Health Solutions.

That began this year, Reddy said, when “Arizona actually ended up becoming one of the most stable insurance marketplaces.”

It’s a change from 2014, the first year of the ACA marketplace, when HHS said there were 10 insurers competing to offer more than 100 qualified health plans. Prices were low and competition was high, causing a shakeout that left the state by last year’s open enrollment with just two or three insurers – fewer in rural counties – offering only five plans, according to the HHS.

That led to the 117 percent increase in premiums in the state in 2017, highest in the nation and a frequent target of Trump’s.

“We had all these insurers, the premiums were very low, then the premiums spiked drastically and we lost so many of the insurers,” Reddy said. “So, this is not good for consumers.”

While prices have stabilized, they are still 134 percent higher than the low opening-year premiums of 2014, but experts say they think enrollment will stabilize along with the market this year. After peaking at 205,666 patients in 2015, Arizona enrollment fell to 165,758 this year, a number that is expected to stay level in 2019.

“About in the beginning (of ACA) roughly 200,000 people purchased plans from healthcare.gov,” said Allen Gjersvig, director at the Arizona Alliance for Community Health Centers. “In recent years, we’re seeing nationally the uninsured rate to start to increase again and I believe it’s related to the rhetoric around repeal and replace.”

Republicans in Washington have tried unsuccessfully for years to repeal Obamacare, a 2012 law that requires people to carry health insurance or pay a penalty on their taxes. But the law expanded Medicaid eligibility and included tax rebates for lower-income individuals to make coverage affordable.

The law also included a number of popular provisions, including requirements that insurers grant coverage to people with pre-existing medical conditions and allow children to stay on their parents’ plans until age 26.
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The Trump administration has taken several steps to rein in the law, such as reducing advertising budgets and enrollment periods, and relaxing rules to allow insurers to offer less-strict, short-term policies. And as part of a tax cut bill it passed last year, Congress weakened the mandatory coverage provision, leaving the future of the law in doubt.

Critics charge that the law has led to costly and impersonal coverage, but supporters say it has led to sharp reductions in the number of uninsured in the nation. Gjersvig said the uninsured rate in Arizona was over 20 percent before the law; the U.S. Census Bureau put that number at an 10.5 percent in 2017, still higher than the national uninsured rate of 8.7 percent.

Arizonans who go to the marketplace this year will see a number of providers offering range of options. Maricopa County customers will see four insurers offering policies that are, on average, 17 percent cheaper than this year. Pima County has three insurers offering coverage at premiums about 6 percent lower than 2018.

Blue Cross Blue Shield of Arizona is the only insurer offering coverage in other counties. Most will see lower premiums – a 25-year-old non-smoker purchasing a silver plan in Graham, Greenlee and Cochise counties, for example, will pay 8.6 percent less for the same coverage than this year, according to data from the Arizona Department of Insurance.

Premiums in Apache, Mohave, Coconino and Navajo counties are actually higher this year, however. The same silver plan for a non-smoker 25-year-old will rise 7.4 percent, from an average of $486 in 2018 to $525 in 2019.

Apache and Navajo counties also had the highest uninsured rates in Arizona in 2017, at 24.7 percent and 13.5 percent respectively, according to the Census.

Even though rural residents face healthcare.gov premiums that are “significantly more costly than in the two large counties,” that does not mean their out-of-pocket costs must be higher, said Gjersvig.

“It’s possible that some people in the rural counties don’t understand that they would qualify for financial help, so that they could shop in the marketplace and end up with a very affordable plan,” he said.

Gjersvig said consumers can look for help and use resources available online or over the phone, which are offered in English and in Spanish.

“People don’t have to be experts. It is confusing and there are some new products available that will further confuse people,” he said.

Experts say shopping around will be even more important this year with the new, low-coverage policies that will hit the market. Reddy said the short-term plans, even though they are cheaper, may not always be a good choice.

“Those plans do not have to offer the 10 essential benefits the ACA offers,” she said. “What happens if you develop some kind of condition or if your loved one that’s insured under you develops some kind of condition … and the insurance that you have been paying for all this time doesn’t actually cover that?”

One thing to keep in mind is that even though Congress weakened the individual mandate penalty, Obamacare is “still it is still the law of the land, it is still this huge umbrella-health legislation,” Reddy said.
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“At the end of the day, this is not so much about liking the Affordable Care Act or not liking it,” she said. “There is not really a comparable other option in the market right now.”

Researchers do not know the cause of acute flaccid myelitis but say it appears to be linked to viruses. They recommend that immunizations be kept up to date, among other healthy habits, and they caution that AFM is quite rate, posing far less of a health threat than the flu. (Photo from NIAID/Creative Commons)

Talen Spitzer was hospitalized two years ago with what turned out to be acute flaccid myelitis. The Queen Creek youth is almost fully recovered now, his mother said. (Photo courtesy Rochelle Spitzer)

WASHINGTON – Talen Spitzer was a healthy 10-year-old from Queen Creek a little more than two years ago when, in a matter of minutes, he lost control of his muscles and his hands were paralyzed.

His mother, Rochelle Spitzer, said doctors didn’t know what was wrong with him at first because everything else seemed normal. But when scans at the hospital later showed lesions on his spine, he was diagnosed with acute flaccid myelitis, an extremely rare polio-like “mystery disease.”

Talen, who is nearly recovered, is one of eight people in Arizona since 2014 who have been confirmed victims of the disease, which has no known cause.

The Centers for Disease Control and Prevention this week said it has confirmed 386 cases of the disease, known as AFM, in at least 38 states and the District of Columbia since 2014, when it first surfaced in the Midwest.There have been 62 cases confirmed in 22 states so far this year, the CDC said.

The disease primarily affects the young, causing weakness in muscles and paralysis in the lower limbs that eventually start rising toward the chest, according to Dr. Sean Elliott, professor of pediatrics at University of Arizona.

​“They (patients) many times are not able to walk, they are unable to move onto legs very effectively, many are unable to even talk effectively,” Elliott said. “The worst patients have had difficulty in breathing because, of course, we breathe using muscles as well.”

Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, said in a conference call Tuesday that AFM is a fairly new disease and there’s still a lot to learn about it.

​Scientists do not know what causes it, how it spreads or even its long-term effects, Messonier said, according to a transcript of the call. They know it isn’t caused by the poliovirus, even though its victims suffer polio-like symptoms, but that it has been linked to other viruses, including West Nile and enterovirus, and environmental factors.

Researchers do know that rates spike in the fall and that more than 90 percent of cases are in children 18 or younger. But Messonier said she is “frustrated that despite all of our efforts,” researchers have not been able to find a cause.

​Despite that, she said there are simple steps parents can take to protect their kids, including making sure children wash their hands, use bug spray and stay up to date on their vaccines.​She also urged “parents to seek medical care right away if you or your child develop sudden weakness or loss of muscle tone in the arms or legs.”

​Recovery is mixed. Elliot said there’s no specific treatment for the disease, and that many patients recover spontaneously. The ones who don’t “have a long road ahead of them with physical therapy, rehab,” he said.

Messonier said she only knows of one patient who had AFM and died in 2017. But Elliott said it appears that patients can die of complications caused by it and not the disease itself.

“If one is unable to breathe and does not get medical care, then yes, the death is due to respiratory failure,” he said. “The illness itself … seems to not cause death.”

During the worse part of his disease, Talen was prescribed with steroids and started undergoing physical therapy seven times a week.

“There’s absolutely no way he would have been able to recover without therapy,” Rochelle Spitzer said.

Talen just turned 13 and is able to run and play soccer, although he still has some limitations, such as struggling to tie his shoes, Spitzer said.

Messonier said AFM is extremely rare, affecting fewer than one person in a million. But Spitzer said it is important to raise awareness: She knows of another Arizona family with a child who has been diagnosed, and believes the condition is a lot “more common than it seems.”

Messonnier said she understands “what it is like to be scared for your child. Parents need to know that AFM is very rare, even with the increase in cases that we are seeing now.”

Elliott said parents should alert, but should keep it in perspective.

“It’s new. It’s scary. It’s a significant disease, but in terms of true national threat from infectious disease, of course, influenza, the flu season is far greater. There were 80,000 deaths from the flu last season in the United States,” Elliott said.

School officials and experts say that teens are attracted to e-cigarettes because they do not produce strong odors, the smoke dissipates quickly and the long-term health effects are unclear. They also say one of the biggest draws is the flavoring, which critics say is aimed towards teens. (Photo by Lindsay Fox via Flickr/Creative Commons)

WASHINGTON — With teen use of cigarettes and other tobacco products declining, Arizona health officials say their “No. 1 priority” now is reducing e-cigarette use, or “vaping,” by high school and middle school students in the state.

It comes as the Food and Drug Administration announced recent steps to reduce youth use of e-cigarettes, a problem that FDA Commissioner Scott Gottlieb said “has reached an epidemic proportion.”

Last year, about 3.6 million high school and middle school students said they had used at least one kind of tobacco product in the previous 30 days, according to the National Youth Tobacco Survey. That was down sharply from 2011, when 4.5 million students in those grade levels reported current tobacco use.

But e-cigarettes were again the most-used tobacco product in 2017, with more than 2.1 million high school and middle school students in the U.S. reporting they had vaped during the year.

“We see clear signs that youth use of electronic cigarettes has reached an epidemic proportion and we must adjust certain aspects of our comprehensive strategy to stem this clear and present danger,” Gottlieb said last month.

Gottlieb said the FDA recognizes that e-cigarettes can help people wean themselves off regular tobacco products, but that the agency cannot “allow a whole new generation to become addicted to nicotine” at the same time.

But Gregory Conley, the president of the American Vaping Association, said the steep reductions in tobacco use overall counter the claim that e-cigarettes are a “gateway” to other tobacco products.

“From 2011 onwards, we saw rapid increases in experimentation with the vaping products, but you saw the largest-ever, record-setting decline in teen smoking in the 40-plus years that the federal government has been collecting data on youth smoking,” Conley said.

“So what kind of a gateway is vaping where you just had five-, six-, seven-year period of massive experimentation occurring with youth and we saw the largest-ever declines in teen smoking?”​Wayne Tormala, a bureau chief at the Arizona Department of Health Services, said that more-recent state numbers have shown “vape use growing,” and that’s a concern for state officials.“We’ve put vape as our number one priority because we’ve had great reductions in smoking combustible cigarettes,” Tormala said.

Tormala said a program called STAND – Students Taking a New Direction – that was created about six years ago to address tobacco use has been refocused toward vaping for roughly a year.

“We have like 32 different coalitions in every area of the state, and they are on the ground working with local city councils to get ordinances in, and working with educating each other,” Tormala said.

School officials and experts say e-cigarettes are attractive to students because they do not produce strong odors, the smoke dissipates quickly and studies are unclear about the long-term health effects of vaping. But they say one of the biggest draws is the flavoring, which critics say is aimed toward teens.​​“Is it really targeted to youth? I would say yes,” said Jessica Hugdahl, state coordinator of Students Against Destructive Decisions in Arizona. “I don’t know a lot of adults that eat cotton candy, gummy bears and grape soda.

“I’m not saying it doesn’t happen, but clearly it is a product that is targeting youth,” she said.

Vape flavoring was one of the areas targeted, along with labeling, when the FDA sent letters to the five major e-cigarette manufacturers last month, giving them 60 days to come up with a plan for reducing youth sales, or have limits imposed on them by the government. That effort expanded Friday, when the FDA sent lettersto an additional 21 e-cigarette companies, questioning the marketing of 40 products.

“I believe certain flavors are one of the principal drivers of the youth appeal of these products,” Gottlieb said when the September letters were filed.

Conley said the industry doesn’t oppose “having a reasonable regulatory situation at the FDA” when it comes to marketing and labeling, but that the “industry and consumers are not going to lay down on flavors.”

“The flavors themselves, not the labels or the marketing, the flavors themselves are critically important to getting smokers off of cigarettes,” Conley said.

But critics say labeling often comes in colors and various designs that appeal to youth. Another issue they see is that e-cigarette use is so easy to conceal.

Hugdahl said some e-cigarettes are so small that “kids can wrap their hands around it, they can hide it and when the teacher’s back is turned they will smoke it.”

“The kids will tell me all the time that they see it in class, in front of the teacher,” she said.

At Cave Creek Unified School District, the parents’ portal on the district’s website includes information on how to identify e-cigarettes.

“One of the vape designs, if you look at it, you would think it was a flash drive, and another one looks like a credit or debit card, so parents wouldn’t be suspicious of anything,” said Gina Durbin, Cave Creek’s director of education and community services.

Conley said “no one actually believes” that an e-cigarette could be disguised as a flash drive, saying it would clearly stand out.

The Scottsdale Unified School District looked to educating parents and students on the dangers of substance abuse and nicotine addiction after an increasing number of students wer caught with e-cigarettes. Students can now choose between suspension or attending a six-hour workshop with their parents.

Besides teaching about substance abuse, the workshops also show “parents how to have those conversations, how to set boundaries. Really kind of teaches the students and the parents on how to work together and open those lines of communication,” said Shannon Cronn, clinical services coordinator for Scottsdale schools.

The Supreme Court began its 2018 term with an Arizona case that asked whether federal age discrimination laws applied to small government agencies like Mount Lemmon Fire District, where two former officers filled a discrimination claim after they were laid off. (Photo by Nathan O'Neal/Cronkite News)

WASHINGTON – An eight-member Supreme Court quizzed both sides Monday in an Arizona case that asks whether small government agencies should be exempt from age discrimination laws, just as small businesses are.

A lower court said they should not, that a government agency of any size should be subject to the law – a ruling that would be “financially crippling” for cash-strapped agencies if allowed to stand, said one advocate challenging the ruling.

The case began in 2009, when the Mount Lemmon Fire District laid off Capts. John Guido and Dennis Rankin, who happened to be the two oldest firefighters in the department at the time. They filed a claim with the Equal Employment Opportunity Commission, citing the Age Discrimination in Employment Act.

But the fire district argued in court that Guido, 46 at the time of the layoff, and Rankin, then 54, were let go not for their age but because they had not participated in volunteer wildland assignments.

The fire district went on to argue that the age discrimination law should not apply to it because it had 13 employees at the time of the layoffs, well below the 20-worker threshold under which a private firm is exempt from the law.

A district court agreed with the fire district. But a panel of the 9th U.S. Circuit Court of Appeals reversed that ruling in June 2017, a ruling at odds with four other circuit courts. That sparked the appeal that led to Monday’s arguments before the Supreme Court.

Guido and Rankin “believed that the definition of employer does not require any particular number of employees in order to cover government entities such as Mount Lemmon Fire district,” said Don Awerkamp, one of the attorneys representing them.

The Age Discrimination in Employment statute defines employer as “a person engaged in an industry affecting commerce who has twenty or more employees for each working day.” It goes on to say that employer “also means (1) any agent of such a person, and (2) a State or political subdivision of a State and any agency or instrumentality of a State or a political subdivision of a State.”

Joshua Rosenkranz, an attorney for the fire agency, argued Monday that the word “also” in the law could be defined as “in addition,” as well possibly meaning “further elaboration of the preceding definition, along the lines of ‘moreover’ or ‘incorporates.'”

That line of reasoning did not appear to sway Justice Neil Gorsuch.

“If we take the best dictionary definition, ‘in addition to,’ the normal meaning, do you lose or do you have some other available argument?” Gorsuch asked. “I’d be delighted to hear it if you do.”

Rosenkranz told the justices that if the 9th Circuit ruling was allowed to stand, it would allow employees and employers to be sued in similar cases, which he said could be “disastrous.”

“If the court reads it (the statute) the way the government reads it, then that will open up liability to thousands and thousands and thousands and thousands of public entities around the country that have 19 or fewer employees,” Jeff Matura, one of Mount Lemmon Fire District attorneys, said after Monday’s hearing.

The case has drawn support from of governmental associations who argue that Congress explicitly intended to carve out small agencies as well as businesses. Amanda Kellar, director of legal advocacy at International Municipal Lawyers Association, said the 9th Circuit ruling “can be really financially crippling for an extremely cash-strapped special district in employment liability.”

“It’s just a balancing that Congress has done in the context of these anti-discrimination statutes by saying, ‘Look, if you fall below a certain threshold of employees, we understand that this can really wipe you out. And so we’re just not going to include you within the definition of an employer,'” Kellar said.

Because the Senate has yet to approve Brett Kavanaugh’s nomination to fill the seat vacated by Justice Anthony Kennedy, the court heard the Mount Lemmon case with just eight justices. Even if he is eventually approved, Kavanaugh would have no role in the case, leaving the possiblity of a 4-4 tie on the court – which would let the circuit court ruling stand.

But Awerkamp is not worried. He said the EEOC and the 9th Circuit got it right, and he expects the Supreme Court to agree.​“Then we will have to take the case to trial, but we think it’s pretty clear that we’ll win when we get to that point,” he said.

Sedona resident Jeff Jeans, a cancer survivor who credits the Affordable Care Act for his ability to get medical treatment, at a news conference in Washington with House Minority Leader Nancy Pelosi and others protesting a lawsuit that challenges the law. (Photo by Renata Cló/ Cronkite News)

WASHINGTON – Health care advocates Wednesday urged Attorney General Mark Brnovich to pull Arizona out of a multistate lawsuit that challenges the constitutionality of the Affordable Care Act, saying the court case could deny coverage to vulnerable state residents.

Planned Parenthood, the Human Rights Campaign and Protect our Care delivered a July 9 letter from Rep. Ruben Gallego, D-Phoenix, to Brnovich that said the suit “not only threatens millions of Americans’ access to care, but jeopardizes the stability of our health care system as a whole.”

The letter went on to say that a ruling against the act, also known as Obamacare, could mean that “all the remaining health care reforms included in the ACA, including a provision that bars insurance companies from denying coverage to patients with pre-existing conditions” would end.

But a spokeswoman for Brnovich said in a statement Wednesday that the attorney general “believes pre-existing conditions should be covered by all insurance companies.”

“Despite the rhetoric, that’s not what this lawsuit is about,” said the statement from Katie Conner, the spokeswoman. “If the court finds that the ACA is now unconstitutional, it’s up to Congress to enact a constitutionally sound health care law that protects all Americans.”

The lawsuit was filed by Texas Attorney General Ken Paxton and 19 other states, including Arizona, joined as co-plaintiffs.

It argues that the core of Obamacare – the “individual mandate” that requires Americans to have health insurance or pay a penalty – was ruled unconstitutional by the Supreme Court, which said nevertheless that the mandate could stand because it was a tax, which Congress is allowed to impose.

But when Congress eliminated the tax penalty in December for those who do not have health coverage, it removed the only justification for the individual mandate, rendering the law unconstitutional, the suit argues.

The Trump administration has long tried to undo Obamacare and its Justice Department, which would normally defend the government in such a case, essentially agreed with the states and announced in June that it would not challenge the suit.

That led several states led by Democratic attorneys general – most of the attorneys general in the original suit are Republicans, like Brnovich – to step in and defend the law the Justice Department wouldn’t.

Critics of the original suit called it “frivolous” and “crazy.” Both University of Michigan law Professor Nicholas Bagley and retired Washington and Lee University School of Law Professor Timothy Jost said they don’t believe a decision will be delivered in the coming days. But if the federal judge in Texas hearing the case rules against the law, Bagley said that decision would likely go to the Circuit Court of Appeals, where Bagley said it probably is “not going to get anywhere.”

But that has not stopped critics from predicting what could happen if the law is overturned – and that decision is ultimately agreed to by the Supreme Court. That possibility is being raised by Democrats in their questioning this week of Supreme Court nominee Brett Kavanaugh.

At a news conference Wednesday in Washington, House Democrats said that the ACA has saved people with pre-existing conditions by prohibiting insurance companies from denying them coverage.

Sedona resident and cancer survivor Jeff Jeans told the news conference that a pre-existing condition insurance plan he got under the ACA saved his life. Doing away with it is just another way the Trump administration is chipping away at coverage, he said.

“The recent expansion of short-term and association junk insurance plans is not helping our plight,” Jeans said. “After House and Senate Republicans voted to try to take away protections for pre-existing conditions, the Republican lawsuit being heard in Texas today and Supreme Court nominee Brett Kavanaugh further accelerates this assault in our well-being.”

Jost believes a decision in the Texas case could come within the next month and that, if the law is overturned, it could result in health care “chaos” that could affect the midterm elections and Kavanaugh’s nomination.

Jeff Jeans, from Sedona, talked at Capitol Hill today at a News Conference held by minority leader Nancy Pelosi and other Democrats, in which people with pre-existing conditions spoke about the Affordable Care Act. pic.twitter.com/TQPbeaNrZn

WASHINGTON – Arizona Sen. Jeff Flake said he was impressed by Supreme Court nominee Brett Kavanaugh’s “respect for the law” and his “kindness and decency.”

Sedona resident Jeff Jeans was in Washington to say he worries that, as justice, Kavanaugh could be a death sentence for cancer patients like him, who were saved by the pre-existing conditions provisions of the Affordable Care Act.

The two Jeffs represented different sides of the debate as the Senate Judiciary Committee held the first of several days of what are expected to be contentious hearings on the nomination, with Tuesday’s proceedings interrupted often by protesters.

While the hearing split along party lines, Flake did side with Democrats on one point, saying he wanted to know how Kavanaugh would stand on the separation of powers issue if he had to rule on a case involving President Donald Trump, who nominated him.

“A lot of the concern on the other side of the aisle stems from the concern of an administration who doesn’t seem to understand and appreciate separation of powers and the rule of law. I have that concern as well,” Flake said during his opening statement Tuesday.

He cited Trump’s feud with Attorney General Jeff Sessions, pointing to two tweets on Monday in which the president accused Sessions of bringing “Obama era investigations of two very popular Republican Congressmen … to a well-publicized charge just ahead of the Midterms.”

Flake said such examples of the administration’s pressure on Sessions to “punish his (Trump’s) enemies and relieve pressure on his friends” is reason for concern, and something he plans to question Kavanaugh about.

But Flake was otherwise conciliatory toward Kavanaugh, saying he was impressed by Kavanaugh’s participation in two Boston marathons, which he said showed a competitive spirit, and his community work as a coach for his daughter’s elementary school basketball team.

Those were light moments in an otherwise combative day of hearings.

Not only did Democrats ask whether Kavanaugh could rule fairly on a case involving Trump but they also demanded – repeatedly and unsuccessfully – for a delay in the hearing while they sought more records on the nominee’s background.

Democrats argued that they had been given less than 10 percent of documents on Kavanaugh, who has been a judge on the D.C. Circuit Court for 12 years as well as being staff secretary to President George W. Bush and a lawyer on the independent counsel investigating President Bill Clinton.

Republicans countered that there have been hundreds of thousands of documents already provided on Kavanaugh, more than for any previous Supreme Court nominee. They said that the more than 300 court opinions Kavanaugh has written, and the thousands more cases he has been part of on the circuit court, should be more than enough to prove he is qualified for the job.

But it’s Kavanaugh’s record as a judge that worries people like Jeans.

He was a lifelong Republican before being diagnosed with throat cancer in late 2011. Jeans said the Affordable Care Act saved his life: His wife enrolled him in the Pre-existing Conditions Insurance Plan in April 2012.

“Without an insurance card they were going to let me die,” Jeans said.

He has been cancer-free for more than six years, but worries that others will not be as lucky if Kavanaugh is confirmed.

Jeans said a lawsuit by 20 states – including Arizona – that challenges the constitutionality of the ACA could be ruled on soon by a federal judge in Texas. If the judge finds the law unconstitutional, it could end up before the Supreme Court.

Jeans said Kavanaugh has ruled against the law before and worries he would not rule in its favor on the high court.

“The law’s already been decided by the Supreme Court once,” Jeans said. “He would be legislating by changing that decision.”

Jeans was in Washington to rally against Kavanaugh’s appointment, but was not part of the protests in the Judiciary Committee hearing room Tuesday. As senators tried to talk over them, protesters yelled, “Stop this hearing,” “Vote no,” “Protect women’s rights” and more, usually right after a Republican senator spoke in support of the nomination.

Several were escorted out of the hearing by the Capitol Police and arrested.

Other protesters gathered outside the hearing in the atrium of the Hart Senate Office Building. Some held signs, others dressed in costumes to make a statement and some told personal stories about their reasons for opposing Kavanaugh.

The protesters that seemed to grab the most attention were a group of women dressed as characters from “The Handmaid’s Tale,” in reference to the novel and television series about a misogynistic future dictatorship in which women have no rights.

They were with Demand Justice, which was there opposing Kavanaugh’s nomination “because he represents the greatest threat to the right to legal abortion” since the court recognized that right in its Roe v. Wade ruling, said Demand Justice adviser Lori Lodes.

WASHINGTON – Applause is not often heard around the Vietnam Veterans Memorial, but that was the response Saturday from a few hundred people who came to see Cindy McCain place a wreath in honor of her husband, Sen. John McCain.

The wreath-laying was one of the last events in a week of celebrations of the late Arizona senator, who spent more than five years as a prisoner of war in North Vietnam.

Those who turned out for the wreath-laying included graying veterans of that war and South Vietnamese refugees who credit McCain with helping them get out of their country, which was overrun by the North in April 1975.

“We say thank you to all Americans who opened doors, arms and hearts for us. Thank you,” said Quyen Ngo, who was there with others who said they were children of Vietnamese political prisoners who were later helped to come to the U.S.

The Saturday morning event was brief, literally a stop between the Capitol, where McCain lay in state, and Washington National Cathedral, where hundreds of political figures gathered for his funeral.

Under a cloudy sky, Cindy McCain walked to the vertex of the black granite walls flanked by Defense Secretary James Mattis and White House Chief of Staff John Kelly, both former generals. A sailor helped her place the large wreath of red, white and blue flowers; McCain stood in front of it for a moment before walking away.

It was not long before other visitors began placing signs and notes honoring John McCain for his service as a soldier and a senator.

Ngo, Vinh Ho and Thien Thauh Nguyen were among those who came up after McCain left and stood before the wreath.

It was the second time in as many days that the three honored McCain, who died a week ago after a yearlong battle with brain cancer. The Vietnamese said they spent hours in line Friday to visit the senator as he lay in state in the Capitol Rotunda.

“He literally campaigned for the Americans to save the lives of the South Vietnamese political (prisoners) and their families to come to the U.S., to be able to live here, to have freedom in America,” said Ho, a social worker in Philadelphia who traveled to Washington to honor McCain.

They left signs that thanked McCain and the American people, who they said “saved our lives.”That drew the attention of other visitors, including Paul Stancliff, 74, a Vietnam veteran and National Park Service volunteer who introduced himself to the three. They talked and took photos together before Ngo helped Stancliff back to his motorized scooter.

Stancliff met his wife, Cindy Hollender-Stancliff, at the Wall. They have been volunteering with the National Park Service for decades and try to help veterans who may be suffering from post-traumatic stress to overcome their fears when they visit the wall.

But Stancliff said they were at the Wall today specifically to pay respect to McCain. Although he believes the word “hero” is overused, Stancliff said he thinks McCain was one for always putting the country first.

“It was not about what was going to make John McCain more famous, more important, whatever,” he said. “He run for president twice. He was defeated twice. Imaterial. What he was doing was what he felt was best for the country.”

WASHINGTON – President Donald Trump reversed course Monday and ordered the flag over the White House lowered to half-staff to honor Arizona Sen. John McCain after briefly raising the flag Monday, less than two days after the senator’s death.

While there is no requirement that the flag remain at half-staff more than two days for a sitting member of Congress, experts on etiquette and flag protocol called it “disappointing” that the White House broke with the tradition of lowering the flag until after burial.Most chalked it up to the long-running animosity between Trump and McCain.

“I think it’s pretty clear to everyone why the president did it,” said Peter Ansoff, a flag expert and president of the North American Vexillological Association – a group dedicated to the study of flags and flag usage.

Ansoff said the White House didn’t break any rules when it raised the flag to full staff, but that it was “disappointing” to see partisanship influence his decision.

U.S. law states that when the president or a governor orders a flag to be lowered to half-staff it should remain there for a set length of time – from 30 days for a current or former president to 10 days for a Supreme Court chief justice or House speaker and others, and until burial for Cabinet secretaries, governors and others. For members of Congress, it only says the flag should be lowered “on the day of death and the following day.”​

The flag remained at half-staff on the Capitol on Monday, as it did through the rest of Washington – except, briefly, the White House. (Photo by Brendan Campbell/Cronkite News)

But recent precedent in similar situations has seen the flag kept at half-staff for much longer.When Sen. Ted Kennedy died in 2009, President Barack Obama ordered the flag to remain at half-staff for four full days, CBS News reported at the time. Flags on Capitol Hill were still at half-staff Monday.​Raising the flag over the White House back to full height was quickly noticed Monday morning. After facing criticism from news outlets and experts, the president issued a proclamation Monday afternoon that ordered the flag to be lowered again.

“Despite our differences on policy and politics, I respect Senator John McCain’s service to our country,” Trump’s statement read. “And, in his honor, have signed a proclamation to fly the flag of the United States at half-staff until the day of his interment.”

Trump went on to say that he had asked Vice President Mike Pence to speak Friday, when McCain lies in state in the Capitol Rotunda, and that he has authorized a military transport to bring McCain’s casket from Phoenix and military support for his burial at the U.S. Naval Academy this weekend.

Trump also said he asked White House Chief of Staff John Kelly, Defense Secretary James Mattis and National Security Adviser John Bolton to attend McCain’s funeral ceremony on his behalf.

Crystal Bailey, director of the Etiquette Institute of Washington, said it is not likely that the decision to raise the flag was an oversight by the White House. She said the decision to put the flag back at full height so soon after McCain’s death could be seen as a message.​“Very rarely will I look at anything that’s done in Washington as someone didn’t notice what was going to happen or the outcry there would be after,” Bailey said. “Because of the political turmoil that took place between the president and Sen. McCain, it is really unfortunate that it would come down to the flag.”

Linda DeJesus remembers the last Thanksgiving she had with her daughter, Taja, who cooked for the entire family a few months before she was killed at her apartment complex in San Francisco. (Renata Cló/ News21)

Woods, the Oakland Police Department LGBTQ liaison, said she prepares herself to read the names of people she knows on the list of the year’s victims before each Transgender Day of Remembrance.

“If you run a transgender program anywhere, anywhere in the world, I can honestly say almost anywhere in the world, it’s not a matter of if somebody is going to get killed, it’s when,” Woods said.

Since 2016, at least 66 transgender people have been murdered in the United States, according to the Human Rights Campaign. A News21 analysis found more than half of the victims were people of color and at least 29 of the cases are still under investigation.

Only one case was classified as a hate crime, even when LGBTQ advocates and victims’ communities argued they were targeted for their gender identity.

Transgender victims’ cases are frequently complicated by the circumstances surrounding their deaths, which makes it difficult to classify their homicides as hate crimes. The victims are often killed by a romantic partner, sex work client or stranger.

“It’s important to remember that hate crimes occur in all sorts of different contexts. I think people often, when they think about them, they immediately go to something on a street outside a gay bar with a bunch of young men,” said anti-LGBTQ hate crimes expert Gregory Herek. “It’s a common scenario, but hate crimes are also committed in families, in the home, in schools, in the workplace and by all sorts of people.”​China Gibson, a 31-year-old African-American transgender woman, was shot in the back between eight and 10 times while exiting a shopping center in New Orleans in February 2017. Gibson’s mother, Tammie Lewis, and her sister, Iona Maxie, believe the murderer was a lover who hoped to conceal his sexual relationship with Gibson to avoid questions regarding his sexuality.

Tammie Lewis, the adoptive mother of China Gibson, holds photos of China as she lays in her bed in Sacramento, California. Tammie has preserved China’s room in the wake of her murder. (Connor Murphy/ News21)

“I think China was killed because people want to live a certain lifestyle, but then have a closeted lifestyle that they don’t want to be outed about,” Maxie said. “China was a person, when she met men, she told them exactly who she was, and you have to decide going forward if that’s what you want to be a part of whether people find out or not. I just think the person just didn’t want people to find out. And that’s why China was killed.”

The New Orleans Police Department officers who responded to Gibson’s shooting did not categorize her murder as a hate crime in the incident report. In subsequent statements, law enforcement officials have said the murder is not being considered a hate crime.

Kevin Griffin, Gibson’s cousin, said while the details surrounding her murder are ambiguous, there’s little reason Gibson would have been targeted, making her gender identity a potential motive in her killing

Kevin Griffin, Gibson’s cousin, said while the details surrounding her murder are ambiguous, there’s little reason Gibson would have been targeted, making her gender identity a potential motive in her killing.

“This is one of those people who would give you the shirt off their back. People say that, because it’s cliché and cool, but this was the person China was,” Griffin said. “Would not do any harm to anyone. She just wanted to be who she was and she didn’t want any static or any friction so she wouldn’t give it.”

Iona Maxie, China Gibson’s cousin, looks at photos of China. Maxie said learning of China’s killing was one of the worst moments of her life. (Connor Murphy/ News21)

Even if law enforcement found Gibson’s killer and confirmed a gender identity bias motive in her murder, the ability to pursue hate crime charges on a state level is limited in Louisiana. While the state’s hate crime statute defines sexual orientation-based crimes as hate crimes, there is no such provision for gender bias-based crimes, leaving little legal recourse other than federal hate crime charges.​Other states like Louisiana without gender identity provisions have seen the most murders of transgender individuals in recent years. Since 2016, eight transgender people have been killed in Texas, six in Florida, and five in Ohio and Georgia. Seven transgender women were murdered in Louisiana during that time.

Kevin Griffin visits his cousin’s crypt, which is decorated with flowers and photos from her drag shows. China Gibson was shot and killed in New Orleans in February 2017. (Megan Ross / News21 )

In states that can pursue hate crime charges in gender identity cases, justice is not always a guarantee.

California has hate crime and non-discrimination laws that cover individuals targeted for their gender identity or gender expression, but the state’s transgender population is still vulnerable.

​Taja Gabrielle DeJesus, a 36-year-old transgender Latina woman from San Francisco, was stabbed to death in her apartment complex in February 2015. Neighbors reported hearing an argument between Taja and a man, and called the police, said Linda DeJesus, Taja’s mother.

When first responders arrived at the scene, they found Taja in the stairwell. She had been stabbed nine times and was pronounced dead. By the time officers found the man, who fled the apartment, he had committed suicide, DeJesus said.

Although DeJesus believes the murder was a hate crime, it wasn’t classified as such by investigators. She told News21 that detectives said the suspect, who was going through a divorce, was trying to reconcile with his ex-wife.

“They considered it an argument that got escalated, got out of control,” DeJesus said. “He killed her, and in my heart I believe that no, he didn’t want anyone to know that he was with a transgender woman.”

Before transgender individuals are victims of fatal violence, they can face a number of factors that put them at higher risk for hate, murder and discrimination.

A 2011 report published by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, two national LGBTQ advocacy groups, found more than 1,100 of the over 6,000 transgender respondents reported being homeless at some point. More than 950 said they had to find alternative sources of income, like drug trafficking or sex work, to survive.

Before she was killed, Taja was struggling to get by, and had turned to sex work to survive, her friend and sobriety sponsor Danielle Castro told News21. She said she ran into Taja while going home from work about two weeks before she died.

“I took her home to Bayview where she lived. She wanted me to see her place and the area felt unsafe, but we went inside and she had bare minimum,” Castro said. “I could tell she was really struggling.”

Among the challenges the transgender community faces, there’s also a lack of trust in law enforcement. The National Center for Transgender Equality survey reported that almost 3,000 respondents said they were uncomfortable reaching out to the police for help.

Woods, who trains Oakland Police Department officers to work with the LGBTQ population, said most law enforcement officers have a “very limited” perspective on the transgender community. Most, Woods said, only engage with transgender folks in an emergency response capacity or when a transgender individual is committing a crime.

Castro, who is also a transgender woman, told News21 she had a bad experience with police officers days after Taja DeJesus’ funeral.

Danielle Castro looks at old pictures from her family. She talked to News21 about transgender issues and the murder of her friend Taja DeJesus. (Renata Cló/News21)

Castro said she was sitting in front of a bar in the Castro District, a gay neighborhood in San Francisco, while a march against transphobia took place. The bar manager came out and told Castro to leave. When she refused, he shoved her.​“He was saying transphobic things, and I couldn’t believe that he put his hands on me and was so forceful when I was obviously disabled,” said Castro, who was dealing with hip problems at the time.

The manager called the police, and Castro said the officers refused to take her statement. ​“The police came and they were awful. Just awful,” Castro said. “I wanted to file charges, but they said they couldn’t do a police report there because it was out of their district.”

Castro said she later found out the officers had lied to her, and could have done a police report there.

Of the 39 closed transgender murder cases recorded by the Human Rights Campaign since 2016, only one had hate crime charges filed by the local district attorney’s office. The police involved did not say if they investigated the case as a hate crime homicide.

NEW YORK CITY – “Homos deserve AIDs,” the sign reads. “Homosexuals end up in hellfire,” another reads. They were held up by Pastor Aden Rusfeldt and a small group of his followers who had come to New York City’s 2018 Gay Pride March in late June.​Protected by police in a roped-off area, they chanted homophobic slurs to the people walking by.​Most people ignored Rusfeldt and his group from the Key of David Christian Center in Philadelphia, but a few cursed at them, or called them wrong, or tossed their water bottles at them.

Members of the Key of David Christian Center yelled slurs at the 2018 New York City Pride March goers from a police-protected area. (Renata Cló/News21)

​After the march, Rusfeldt, 41, talked to News21.

Rusfeldt said that his goal at the gay pride march and other events is to spread his interpretation of the word of God and help Christians “get bolder in their faith.”

At least 10 times a month, Rusfeldt estimates that he and a handful of other members of the Philadelphia church hold protests against the LGBTQ community and Islamism at college campuses and events around the Northeast.

The Anti-Defamation League has been tracking Rusfeldt’s activities in the Philadelphia area since late 2016. Jeremy Bannett, associate regional director of ADL in Philadelphia, describes Rusfeldt’s message as “an extreme interpretation of Christianity characterized by homophobia, Islamaphobia, misogyny and other forms of hate.”

James Ross, 28, a Philadelphia businessman who was part of Rusfeldt’s group at the New York City march, explained his own belief.

“In this day and age, I think everybody has heard the good gospel of what God will do, but they miss all of it,” Ross said. “I have heard many people running up and saying God loves everyone, and that’s not the truth.”

Activist and art creator Ezequiel Consoti, who was watching the march, said Rusfeldt’s protest is “just sad.”

“New York City values itself in love, acceptance and inclusivity,” Consoti said. “It’s just these four other people against thousands of people who just want to express love for one another. They are just being hateful.”​Chelsea DeMarte, co-president of Gaylesta, the psychotherapist association for gender and sexual diversity located in San Francisco, described protests by so-called religious groups against the LGBT community as incredibly disturbing to people.

Chelsea DeMarte, co-president of Gaylesta, talked to News21 about the impacts of hate to LGBTQ individuals at her house in the San Francisco Bay Area. (Renata Cló/News21)

Religious (hate) speech can be very harmful for individuals struggling to navigate through their sexual identity and faith, DeMarte said.

When somebody from a religious organization is openly saying negative things about LGBT people or that they are going to hell, they are coming from the assumption that it is OK to impose your beliefs onto somebody else because you believe they are abnormal or deviant and that is not OK,” she said.

Rusfeldt hasn’t always been a street preacher.

Before getting his degree at the Abundant Life Christian School in Houston, he was in the investment business. In 2008, he was fined more than $3.2 million by the U.S. Commodity Futures Trading Commission for fraudulent activity in Texas, according to a press release from the U.S. Commodity Futures Trading Commission.​Rusfeldt said he has repented in recent years. He was “headed to hell,” but God is loving, he said.

Most 2018 New York City Pride March goers ignored the street preacher. (Renata Cló/News21)

After Hurricane Maria made landfall, San Sebastian’s cleaning efforts proved successful, making the town debris-free within five days time, said Mayor Javier Jimenez Perez. (Photo by Lerman Montoya)

Mayor Maldonado held an event at Morovis city hall to honor the women who helped her after Maria hit the island on this year's International Women's Day. (Photo by Renata Cló)

In Morovis, a municipality of 30 thousand people in the north of Puerto Rico, more than half of the population was still waiting for power to be restored on this year's international women's day.

Sitting in her office on March 8, Mayor Carmen Maldonado said she wanted to honor the women who helped provide assistance for her people when Hurricane Maria hit the island on Sept. 20, 2017.

"Today I have an activity downstairs recognizing every female volunteer that was with me handing out food, handing out water, helping every community of our municipality and working in every corner of our town," she said.

When Maria hit Puerto Rico, it left behind roads and highways with no accessibility. Households were without water and power. Communication lines were damaged, which made it almost impossible for people to make calls or access the internet.

Right now, months after the storm, the electric crisis is still a pressing issue for a number of municipalities. Cities all over Puerto Rico rely on a struggling public company with an uncertain future.

At the same time, mayors from different parts of the island feel a lack of support from government agencies and are left to cope with the situation leaning on help from non-profits, private donations and their own communities.

The Federal Emergency Management Agency, or FEMA, and the U.S. Army Corps of Engineers have been spearheading recovery efforts.

​However, Maldonado said the response was slow. Although FEMA grants individual assistance to Puerto Ricans, Maldonado estimated about 60 percent of her citizens had not received any help.

FEMA said the Individuals and Households Program is "intended to meet basic needs and supplement disaster recovery efforts," and it is designed to help people without insurance. The organization also said that it has provided close to 17 million dollars to individuals in Morovis.​When Maldonado went out on the streets to check on her constituents once the hurricane passed, she said she found desperate people and families in tears.

​Many of them didn't have water or food. She went to the schools in town and took the school lunch food to give it to the people in need.

Maldonado said people tried preparing for the hurricane, but a lot of them didn't have the means to get ready for a storm in the first place. The U.S. Census estimated that at least 50 percent of the Morovis population is living below the poverty line.

The mayor says a lot of them lost their houses and were in the streets.

To worsen the situation, supermarkets and warehouses were closed. Most of the local businesses were also shut down because operating with generators was unaffordable.

Some of the local commerce only started reopening in March while most of them were still closed six months after Maria.

"The only few business that are opened right now are open only to maintain their names, instead of remaining closed, and are trying to get back in their feet little by little," Maldonado said.

Zulma Negrón, 43, owner of a flower shop near the main square in Morovis, had her business closed for more than three months. Even though she lost on sales, the florist still said she was grateful.​"We went through a rough patch but we learned a lot, you know?" she said. "The lesson was big and good. First, we have to be prepared for everything no matter what or when. And second, to share and to thank what we have in our daily lives."

The electrical crisis in Puerto Rico started long before the 2017 hurricane season. A year before Maria, the island's entire electrical system collapsed leaving the entire population without electricity for over 12 hours.

The Puerto Rico Electric Power Authority, or PREPA, is the utility company responsible for providing electricity to 3.5 million American citizens living on the island.

PREPA's debt in March 2017 was estimated to be of almost nine billion dollars, according to a memo published by a congressional subcommittee. The company also lost approximately 30 percent of its workforce since 2012, mostly due to retirement, which restricted the company's ability to respond to challenges.

In January, governor Ricardo Rosselló announced a plan to privatize the company and generate 30 percent of the island's energy using renewable sources. But to date, the government hasn't shared many details of the sale.

Looking at ways to feel more independent and the current rate of 40 percent of people still without power in Morovis, Maldonado started looking for alternatives of her own.​"Neighborhoods further away won't have energy for a long time. I am looking at a way that we could invest in a renewable energy system with solar panels," she said.

​Early on April, Maldonado went to Miami to attend the Clinton Global Initiative Conference in order to get help to develop this project.

Professor Efraín O’Neil-Carillo believes mayors across the island have alternatives to have independence from PREPA and provide cheap sustainable energy to their people. (Photo by Tyler Paley)

That's not a new idea on the island. Efraín O'Neill-Carrillo, an electrical engineering professor at the University of Puerto Rico in Mayagüez, argues that some communities in the island have been searching for clean energy alternatives for at last five years.

Before Maria, O'Neill-Carrillo had been working on building a solar power plant in which energy would be shared by a group of households in a community located in the south of Puerto Rico.

In 2010 the legislature passed the Public Policy on Energy Diversification by Means of Sustainable and Alternative Renewable Energy in Puerto Rico Act that set the goal of 20 percent of renewable energy generation for PREPA by 2045.

From 2009 to 2012, PREPA signed renewable energy contracts that consisted in utility scale projects. The problem is that PREPA sets an unreasonable limit in the amount of renewable energy the island can integrate in its electrical infrastructure, said professor O'Neill-Carrillo.

In fact, in July 2017, O'Neill-Carrillo and five other electrical power researchers signed a written testimony addressed to the Financial Oversight and Management Board for Puerto Rico, saying that, "in order to support the dominance of the centralized, fossil-based model and resist a renewable-based transformation, it is important to clearly explain where the infamous 580 MW limit to renewable energy comes from and why it is NOT correct."

As a way to address the issue, O'Neill-Carrillo was advocating and working for community systems that can work in different ways.

"It can be one big system that is chaired by different people in the community. Or it can be small systems spread around people's rooftops whose economic benefit is distributed among the community members," he said.

In San Germán, a town about 75 miles west of Morovis, Mayor Isidro Negrón said he doesn't believe the generation of electricity through renewable sources is attainable in the island.​Negrón said he doesn't have the money to make this kind of investment and doesn't think the insular government will invest in it anytime soon.

"The generation of energy through sunlight, through the wind, through the waves, all of this is feasible," he said. "We are an island surrounded by water, where there is wind, where there is sun, where there are waves.

"Every government promises to go in that direction, but when they are in power, there are strange forces that grab them and stop them from doing so because of other interests."

However, O'Neill-Carrillo believes that mayors have a privileged position between the people, the legislature and the top of the executive branch of government and could work as facilitators of the clean energy transition in the island.

"I think there's a very important role to be played [by mayors]. Not the role of a 'little PREPA' or a little utility that just oversees the microgrid. Community microgrids or community solar systems should be run mostly by the community," he said.

Mayor Isidro Negrón said he doesn’t believe that fully privatizing PREPA would be a good solution for Puerto Rico. (Photo by Tyler Paley)

San German has population of about 30 thousand people. It wasn't until late January when the mayor said about 92 percent of the people had electricity again.

"The worst hurricane was after Maria passed through Puerto Rico when there was no power, when there was no water, when there wasn't an effective communication between insular government and municipal government," Negrón said.

The mayor estimated about 70 people died in San Germán as a consequence of the lack of electricity.

"Many people who needed dialysis weren't able to continue their treatment without power; others with diabetes didn't have an appropriate place to store their medications. Even some who were already living in bed and needed oxygen didn't make it," Negrón said.

After posting a few videos on Facebook asking for help, Negrón started getting relief from people and foundations on the mainland and from the insular government at last.

He created a volunteer group led by a retired National Guard colonel that had control over the donations and aid. At first, they used the facilities of the water park to hand out food and water. Later they started dividing into groups of four and provided assistance house by house.

Mayor Javier Jimenez Perez of San Sebastian took matters into his own hands, creating the Pepino Power Authority, a coalition of retired PREPA workers, to help restore the power grid in San Sebastian. (Photo by Lerman Montoya)

In San Sebastián, a town in the northwest of Puerto Rico, Mayor Javier Jiménez Pérez also assigned groups to go around town dealing with the storm's destruction.

​Besides having city workers assist, Pérez had already selected 25 additional teams to start cleaning the streets to allow residents to move around. He had the town obstacle-free in five days.

Pérez predicted water and power could go down; before the storm, he arranged three water trucks and five generators. However, a month after the storm the city still didn't have electricity back.

"Many of our people are elderly, are in bed, need machines for treatments, need to follow a certain diet, and because there was no electricity, none of this could be done," he said. "So a lot of people was falling into a deteriorated emotional state and deteriorated physical state."​San Sebastian resident Sheila Enid Vargas, 21, said that since her diabetic uncle couldn't refrigerate his insulin without power, they had to get ice somehow.

​"At first, the ice factories were closed and when they opened, there was enormous lines. And many times they were already out of ice when it was our turn," she said.

Sheila Vargas Gonzales’ home was not damaged by Hurricane Maria, but she had to support her aunt and uncle whose home was severely destroyed by flooding and battering winds. (Photo by Lerman Montoya)

Because the Army Corps of Engineers hadn't arrived in town yet to restore power, Pérez decided to create a municipal brigade with retired PREPA workers as volunteers and city employees to identify the power lines that had fallen and fix them.

This initiative was later known in town informally as "Pepino Power Authority."

PREPA and UTIER, the labor union for electrical workers in Puerto Rico, criticized the mayor saying he did not follow protocol. Pérez said the brigade established safety instructions and that while the Pepino Power Authority was operating, they didn't have any accidents.

"We have restored most of the electrical system here in San Sebastian," Pérez said. "Together with the community. We got the people of San Sebastian to take action. Pepino Power goes beyond the groups that were created, it is the people standing up to restore their electrical system, taking control of their own situation."

Mayor José Guillermo Rodríguez said he doesn’t believe investing in sustainable energy alternatives such as solar and wind power would be feasible solutions. (Photo by Tyler Paley)

People from Mayagüez, an university town located on the west coast of Puerto Rico, also went weeks without electricity. ​About 70 percent of the 75 thousand people in town were out of power for almost three months, according to Mayor José Guillermo Rodríguez.

Rodríguez has been mayor of Mayagüez for 24 years now. He has had to deal with many adversities, such as Hurricane George in 1998, a category 4 storm that caused a lot of destruction in the Caribbean. Back then, he learned to prepare in advance.​When expecting Maria, he hired a private company to start re-establishing the city as soon as it was safe. In early March, 20 percent of the people were still expecting power while 15 private brigades worked.

Mayagüez fabric shop owner, Adam Varela, 42, had to deal with a flood in his store that damaged some of the merchandise and the ceiling. He also had to remain closed for a month because of water and electricity issues. ​Varela estimated his losses to be around 30 thousand dollars and predicted it would take him at least three years to get back on his feet.

"First we have to recover, and then try to recover the sales like it was before. And then try to recover the sales we lost because we were closed," he said.

Although Rodríguez criticized the lack of help provided by the insular government to Mayagüez and places responsibility on them for the struggles of PREPA, he recognized the major role the lack of communication played on the situation.

"When there's an emergency plan and something as fundamental as communications fails, you know you are by yourself and you can't rely on anything," he said.

The mayor rejected the idea of renewables as an alternative.

"The problem that we have now is that it sounds nice but the mechanisms that generates renewable energy have a lot of flaws and hidden clauses," he said.

Casa Pueblo, is a community-based organization in Adjuntas that promotes the protection of the environment in Puerto Rico. The Casa Pueblo complex is entirely powered by solar energy. (Photo by Lerman Montoya)

Two hours from Mayagüez, an ecological non-profit in Adjuntas was able to run on its own solar power generation, which is independent from PREPA, the entire time the rest of the island was in the dark.

"Right away people were able to come to Casa Pueblo and it was used as an energy access," said organization director Arturo Massol.​Massol, who is also a professor of microbial ecology at University of Puerto Rico, predicted that light was going to be a huge problem in Puerto Rico during the hurricane season. From the beginning, Casa Pueblo launched a campaign to distribute solar lamps to people in Adjuntas and surrounding towns.

The organization was running independently on solar power for almost 20 years.​"We have been teaching about solar power for a long time, but on this occasion people came here and saw by themselves how reliable was for Casa Pueblo to generate our own energy consumption without the need for all that cable and that infrastructure," Massol said.

Casa Pueblo recently decided to start a project with clean energy and small local businesses. They were responsible for helping Wilfredo Pérez, owner of a barbershop in Adjuntas, to transition to solar power.

Massol said Pérez had the choice to use traditional power or his solar system, but had been running on clean energy since the installation. ​"He is so happy and you can see it in his face. He's getting new customers because people want to get their hair done in his barber shop," the director said.

Wilfredo Perez owns the first solar powered barber shop in Puerto Rico. After Hurricane Maria, his business was left without power and he had to close for a few weeks before he could re-open. With the help of Casa Pueblo and the director, Arturo Massol, Perez re-opened his solar powered barber shop. (Photo by Lerman Montoya)

Casa Pueblo now plans on expanding the project to help small markets in rural areas in Puerto Rico to run on solar energy in order to prepare for possible future crises. With his project, people will likely still have access to food in case of an emergency.

Massol said his organization was completely non-partisan and did not get involved with politics in any level. His plan on energy and view on the future of the island is completely autonomous.​"To us the main issue is energy self sufficiency. How can we reach, as Puerto Rico, energy self-sufficiency. I don't know how can the public or private sector do something. We're going to push for a social response," Massol said.